Auto Adjudication: Retrieve Fee Schedule Rate With This

What is the Fee Schedule Rate?

A fee schedule is a complete listing of fees used by Medicare to pay doctors, other providers, or suppliers. This comprehensive listing of fee maximums is used to reimburse a physician and providers that participate in a fee-for-service payment model. The Centers for Medicare and Medicaid Services (CMS) develops fee schedules for physicians, ambulance services, clinical laboratory services, durable medical equipment, prosthetics, orthotics, and supplies. 

The identified fee schedule is then used to figure how much the provider receives according to the quantity of care. The rate comes after the appropriate conversions and adjustments are made. It is not enough if your claims auto-adjudication system is only capable of reviewing and analyzing data. While there is no doubt that it is beneficial in making claim decisions, you simply get more work done if your system has a specialized feature that works to consolidate all data and properly calculate fee schedule rates.

Identifying A Provider’s Pricing Per Service for the Medical Claims

According to the article published by the American Speech-Language-Hearing Association (ASHA), the Medicare Physician Fee Schedule (MPFS) uses a resource-based relative value system (RBRVS) that assigns a relative value to current procedural terminology (CPT) codes. The relative weighting factor or relative value unit (RVU), derived from a resource-based relative value scale, is the implemented method to determine the compensation of the provider’s services, and it corresponds to the following physician work components: 

Professional component

It is the work expressed in the amount of time, technical skill, physical effort, stress, and judgment for the procedure required from physicians and certain other providers.

Technical component

It is the practice expense expressed in overhead costs such as the assistant's time, equipment, and supplies.

Professional liability component

It is the practice expense expressed for medical malpractice lawsuits out of negligence and errors.

CMS determines the final relative value unit for each code, which is then multiplied by the annual conversion factor (a dollar amount) to yield the national average fee. Rates are adjusted according to geographic indices based on the provider locality.

Automatically Calculate Fee Schedule Rates with QuickCap’s ClaimShop

There’s no question about the efficiency of the claims auto-adjudication system. But is there a comprehensive software in the market that provides a feature that can streamline the process of calculating rates like QuickCap’s ClaimShop does? With ClaimShop, you can easily fetch the right claim pricing for the provided services and obtain the accurate contract amount.

• Retrieve the claim pricing for Diagnosis-Related Group (DRG), Ambulatory Payment Classification (APC), and RBRVS
• Set up whether the pricing is for sequestration, readmission reduction (RRP), value-based pricing (VBP), and health maintenance organization (HMO) payer
• Configure the percentage that will be applied to the claim
• Access edits based on Medicare
• Review the claim pricing status

Knowing how intricate it is to navigate your way around the adjudication process, it is only best that you equip yourself with the right tools. Integrate the most advanced feature for your auto adjudication system so you can be in full control of your workflow and effectively handle medical claims.